Congestive heart failure clinical assessment

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Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

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Diagnosis

Clinical Assessment

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

Cardiac MRI

Echocardiography

Exercise Stress Test

Myocardial Viability Studies

Cardiac Catheterization

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Treatment

Invasive Hemodynamic Monitoring

Medical Therapy:

Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
Diuretics
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Nitrates
Hydralazine
Positive Inotropics
Anticoagulants
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
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Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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Risk calculators and risk factors for Congestive heart failure clinical assessment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Edzel Lorraine Co, D.M.D., M.D. [2]

Overview

Clinical assessment of a patient based on a thorough history taking and physical examination is still the cornerstone in diagnosing heart failure. Based on the gathered data, patients can be assessed if he has an underlying heart condition which necessitates a disease-specific therapy such as amyloid heart disease, a cardiomyopathy, or a developing decompensated heart failure. It is important to investigate for presence of heart congestion so as to treat it the at the earliest stage to avoid deterioration in the quality of life and prognosis.

Diagnostic algorithm for heart failure

 
 
 
 
 
 
 
 
Suspected heart failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NT-proBNP ≥ 125 pg/mL or BNP ≥ 35 pg/mL

or if HF strongly suspected

or if NT-proBNP/BNP unavailable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Echocardiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abnormal findings
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hear failure unlikely, other dignosis shoulb be considered
 
NO
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Heart failure confirmed based on LVEF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
LVEF≤ 40%
 
 
 
 
LVEF=41-49%
 
 
 
 
LVEF≥50%
The above table adopted from 2021 ESC Guideline

[1]


Criteria for definition of advanced heart failure

1. Severe and persistent symptoms of heart failure NYHA class III-IV
2. Severe cardiac dysfunction is defined by at least one of the following:

3. Episodes of pulmonary or systemic congestion requiring high-dose i.v. diuretics (or diuretic combinations) or episodes of low output requiring inotropes or vasoactive drugs or malignant arrhythmias causing >1 unplanned visit or hospitalization in the last 12 months
4. Severe impairment of exercise capacity with inability to exercise or low 6MWT distance (<300 m) or pVO2 <12 mL/kg/min or <50% predicted value, estimated to be of cardiac origin[1]

Clinical Assessment

Framingham Criteria

Major Criteria

Minor Criteria

Boston Criteria of Congestive Heart Failure

Category I: History

Category II: Physical Examination

Category III: Chest Radiography

No more than 4 points are allowed from each of three categories; hence the composite score (the sum of the subtotal from each category) has a possible maximum of 12 points.

The diagnosis of heart failure is classified as "definite" at a score of 8 to 12 points, "possible" at a score of 5 to 7 points, and "unlikely" at a score of 4 points or less.

2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]

INITIAL AND SERIAL EVALUATION (DO NOT EDIT) [2]

Clinical Assessment: History and Physical Examination (DO NOT EDIT) [2]

Class I
"1. In patients with HF, vital signs and evidence of clinical congestion should be assessed at each encounter to guide overall management, including adjustment of diuretics and other medications.[3][4][5][6][7][8] (Level of Evidence: B-NR) "
"2. In patients with symptomatic HF, clinical factors indicating the presence of advanced HF should be sought via the history and physical examination. [9][10][11][12][13][14] (Level of Evidence: B-NR) "
"3. In patients with cardiomyopathy, a 3-generation family history should be obtained or updated when assessing the cause of the cardiomyopathy to identify possible inherited disease. [15][16] (Level of Evidence: B-NR) "
"4. In patients presenting with HF, a thorough history and physical examination should direct diagnostic strategies to uncover specific causes that may warrant disease-specific management. [17][18] (Level of Evidence: B-NR) "
"4. In patients presenting with HF, a thorough history and physical examination should be obtained and performed to identify cardiac and noncardiac disorders, lifestyle and behavioral factors, and social determinants of health that might cause or accelerate the development or progression of HF. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]) "

Initial Laboratory and Electrocardiographic Testing (DO NOT EDIT) [2]

Class I
"1. For patients presenting with HF, the specific cause of HF should be explored using additional laboratory testing for appropriate management. [19][20][21][22][23][24][25][26] (Level of Evidence: B-NR) "
"2. For patients who are diagnosed with HF, laboratory evaluation should include complete blood count, urinalysis, serum electrolytes, blood urea nitrogen, serum creatinine, glucose, lipid profile, liver function tests, iron studies, and thyroid-stimulating hormone to optimize management. (Level of Evidence: C-EO) "
"3. For all patients presenting with HF, a 12-lead ECG should be performed at the initial encounter to optimize management. (Level of Evidence: C-EO) "

Use of Biomarkers for Prevention, Initial Diagnosis, and Risk Stratification (DO NOT EDIT) [2]

Class I
"1. In patients presenting with dyspnea, measurement of B-type natriuretic peptide (BNP) or N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) is useful to support a diagnosis or exclusion of HF. [27][28][29][30][31][32][33][34][35][36][37][38] (Level of Evidence: A) "
"2.In patients with chronic HF, measurements of BNP or NT-proBNP levels are recommended for risk stratification. [37][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55] (Level of Evidence: A) "
"3. In patients hospitalized for HF, measurement of BNP or NT-proBNP levels at admission is recommended to establish prognosis. [37][39][40][41][42][43][44][45] (Level of Evidence: A) "
Class IIa
"4. In patients at risk of developing HF, BNP or NT-proBNP-based screening followed by team-based care, including a cardiovascular specialist, can be useful to prevent the development of LV dysfunction or new-onset HF. [56][57] (Level of Evidence: B-R) "
"5.In patients hospitalized for HF, a predischarge BNP or NT-proBNP level can be useful to inform the trajectory of the patient and establish a postdischarge prognosis. [40][43][46][47][48][49][50][51][52][53][54][55] (Level of Evidence: B-NR) "

Genetic Evaluation and Testing 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]

Class I
"1. In first-degree relatives of selected patients with genetic or inherited cardiomyopathies, genetic screening and counseling are recommended to detect cardiac disease and prompt consideration of treatments to decrease HF progression and sudden death. [15][16] (Level of Evidence: B-NR) "
Class IIa
"1. In select patients with nonischemic cardiomyopathy, referral for genetic counseling and testing is reasonable to identify conditions that could guide treatment for patients and family members.[58][59] (Level of Evidence: B-NR) "

Evaluation With Cardiac Imaging 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]

Class I
"1. In patients with suspected or new-onset HF, or those presenting with acute decompensated HF, a chest X-ray should be performed to assess heart size and pulmonary congestion and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patient's symptoms. [60][61](Level of Evidence: C-LD) "
"2. In patients with suspected or newly diagnosed HF, transthoracic echocardiography (TTE) should be performed during initial evaluation to assess cardiac structure and function. [62] (Level of Evidence: C-LD) "
"3. In patients with HF who have had a significant clinical change, or who have received GDMT and are being considered for invasive procedures or device therapy, repeat measurement of EF, degree of structural remodeling, and valvular function are useful to inform therapeutic interventions.[63][64][65][66] (Level of Evidence: C-LD) "
"4. In patients for whom echocardiography is inadequate, alternative imaging (eg, cardiac magnetic resonance [CMR], cardiac computed tomography [CT], radionuclide imaging) is recommended for assessment of LVEF.[67][68][69][70][71][72][73][74](Level of Evidence: C-LD) "
Class IIa
"5. In patients with HF or cardiomyopathy, CMR can be useful for diagnosis or management. [75][76][77][78][79][80][81][82] (Level of Evidence:B-NR) "
"6. In patients with HF, an evaluation for possible ischemic heart disease can be useful to identify the cause and guide management. [83][84][85][86] (Level of Evidence:B-NR) "
Class IIb
"7. In patients with HF and coronary artery disease (CAD) who are candidates for coronary revascularization, noninvasive stress imaging (stress echocardiography, single-photon emission CT [SPECT], CMR, or positron emission tomography [PET] may be considered for detection of myocardial ischemia to help guide coronary revascularization. [87][88][89][90][91] (Level of Evidence:B-NR) "
Class III (No Benefit)
"8. In patients with HF in the absence of 1) clinical status change, 2) treatment interventions that might have had a significant effect on cardiac function, or 3) candidacy for invasive procedures or device therapy, routine repeat assessment of LV function is not indicated. (Level of Evidence:C-EO) "

Invasive Evaluation 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]

Class IIa
"1. In patients with HF, endomyocardial biopsy may be useful when a specific diagnosis is suspected that would influence therapy. [92][93] (Level of Evidence:B-NR) "
"2. In selected patients with HF with persistent or worsening symptoms, signs, diagnostic parameters, and in whom hemodynamics are uncertain, invasive hemodynamic monitoring can be useful to guide management. (Level of Evidence:C-EO) "
Class III (No Benefit)
"3. In patients with HF, routine use of invasive hemodynamic monitoring is not recommended. [94][95] (Level of Evidence:B-R) "
Class III (Harm)
"2. For patients undergoing routine evaluation of HF, endomyocardial biopsy should not be performed because of the risk of complications. [96][97](Level of Evidence:C-LD) "

Wearables and Remote Monitoring (Including Telemonitoring and Device Monitoring) 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]

Class IIb
"1. In selected adult patients with NYHA class III HF and history of a HF hospitalization in the past year or elevated natriuretic peptide levels, on maximally tolerated stable doses of GDMT with optimal device therapy, the usefulness of wireless monitoring of PA pressure by an implanted hemodynamic monitor to reduce the risk of subsequent HF hospitalization is uncertain. [98][99][100][101] (Level of Evidence:B-R) "
Value Statement: Uncertain Value
"2. In patients with NYHA class III HF with a HF hospitalization within the previous year, wireless monitoring of the PA pressure by an implanted hemodynamic monitor provides uncertain value. [101][102][103][104] (Level of Evidence:B-NR) "

Exercise and Functional Capacity Testing 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]

Class I
"1. In patients with HF, assessment and documentation of NYHA functional classification are recommended to determine eligibility for treatments. [105][106] (Level of Evidence: C-LD) "
"2. In selected ambulatory patients with HF, cardiopulmonary exercise testing (CPET) is recommended to determine appropriateness of advanced treatments (eg, LVAD, heart transplant). [107][108][109][110][111](Level of Evidence: C-LD) "
Class IIa
"3. In ambulatory patients with HF, performing a CPET or 6-minute walk test is reasonable to assess functional capacity. [107][108][112][113][114][115][116][117][118][119] (Level of Evidence: C-LD) "
"4. In ambulatory patients with unexplained dyspnea, CPET is reasonable to evaluate the cause of dyspnea. [120][121](Level of Evidence: C-LD) "

Initial and Serial Evaluation: Clinical Assessment: HF Risk Scoring 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]

Class IIa
"1. In ambulatory or hospitalized patients with HF, validated multivariable risk scores can be useful to estimate subsequent risk of mortality. [122][123][124][125][126][127][128][129][130][131][132][133][134][47] (Level of Evidence: B-NR) "

Source

References

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